Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Postpartum Depression caused by low DHEA, not method of delivery
- James M. Howard (25 February 2005)
-
Can DHEA problems cause double vision, vertigo, nausea and vomiting?
- Dr. Herbert H. Nehrlich (27 February 2005)
-
Zinc and copper deficiencies can cause postpartum depression
- Ellen C G Grant (28 February 2005)
-
Re: Can DHEA problems cause double vision, vertigo, nausea and vomiting?
- James M. Howard (28 February 2005)
-
Re: Can DHEA problems cause double vision, vertigo, nausea and vomiting?
- James M. Howard (1 March 2005)
-
Chips (DHEA) with everything
- Ellen C G Grant (2 March 2005)
-
The anti-depressant effects of oxytocin
- Michel R Odent, NW3 2JR (18 April 2005)
-
Mode of delivery does matter
- Sheena Fleming (10 May 2005)
-
Operative delivery and postnatal depression
- Roshni R Patel, Deirdre J Murphy and Tim J Peters (19 June 2005)
-
Re: Operative delivery and postnatal depression
- Sheena Fleming (27 July 2005)
-
ICAN respectfully disagree
- Melissa A Collins (2 December 2005)
|
|
|||
|
James M. Howard, independent biologist Fayetteville, Arkansas, U.S.A.
Send response to journal:
|
I suggest postpartum depression, and psychosis, depending upon severity, is due to low DHEA. DHEA is provided for the mother and fetus from the adrenal glands of the mother. The adrenal glands of the infant do not start producing DHEA until birth. This means that the DHEA provided by the mother must provide for all of her tissues and the fetus. At the first pregnancy, DHEA decreases significantly in the mother (J. Clin. Endocrin. Metab. 1987: 64: 111). (In 1985, because of my principle hypothesis, I proposed that low DHEA will result in depression and Alzheimer's disease (copyrighted, 1985). In 1997, DHEA was used in "six middle-aged and elderly patients with major depression and low basal plasma DHEA." These investigators reported that: "In both studies, improvements in depression ratings and memory performance were directly related to increases in plasma levels of DHEA and DHEA-S and to increases in their ratios with plasma cortisol levels. These preliminary data suggest that DHEA may have antidepressant and promemory effects and should encourage double-blind trials in depressed patients." (Biol. Psychiatry 1997; 41: 311) Also, the use of DHEA has recently been found effective for treatment of depression (Arch Gen Psychiatry. 2005;62:154-162). I suggest it is the reduction of DHEA postpartum that results in postpartum depression and postpartum psychosis, if the loss of DHEA is severe, rather than the means of delivery. (DHEA has been found to decline post-surgery and this may indicate that c-sections may, in fact, worsen postpartum depression and psychosis in some cases.) Competing interests: None declared |
|||
|
|
|||
|
Dr. Herbert H. Nehrlich, Private Practice Bribie Island, Australia 4507
Send response to journal:
|
Dear Dr. Howard: Is there an illness or even a condition warranting cursory attention that is NOT caused by a "turbulence" in DHEA? It seems to me that every time I see your name I will find readings about DHEA. I do have a hard time believing that so many of these major conditions seem to have a common root. Do you think that schizophrenia is caused by a DHEA deficit during pregnancy and, as a punishment so to speak, it will re-manifest itself later as Alzheimer's and there were a few more conditions that you did mention but.. Well, there is a schizophrenia gene in my gene pool, so I was wondering what exactly the connection with DHEA might be. Do you think I ought to stay out of the pool? I myself have little to fear from postpartum depression or any other depression (after reading stuff about DHEA) but you said you were the expert. I had a high school principal whose wife blamed all illnesses on a lack of vinegar. Apple Cider that is. Competing interests: None declared |
|||
|
|
|||
|
Ellen C G Grant, physician and medical gynaecologist Kingston-upon-Thames, KT2 7JU, UK
Send response to journal:
|
Postnatal depression and depression in pregnancy are theoretically preventable with high quality preconception care. The commonest nutritional deficiencies in women before conception are of zinc and magnesium and these cause unexplained infertility and recurrent miscarriages.1 Zinc deficiency causes depression and other mental illnesses, but this important fact is usually ignored by psychiatrists.2-5 During pregnancy maternal zinc levels fall as copper levels rise, provided copper stores are adequate.6 Years of hormonal contraceptive use before pregnancies increase mineral deficiencies and must therefore be contributing to this extremely high incidence, of 8-15% of women suffering from postnatal depression with increased risk of long term adverse effects on child development.7,8 Deficiencies of trace elements like zinc, copper and magnesium have been implicated in various reproductive events like infertility, pregnancy wastage, congenital anomalies, pregnancy induced hypertension, placental abruption, premature rupture of membranes, still births and low birth weight.9,10 There are no reports of postnatal depression among women who had poor obstetric histories followed by successful pregnancies while eating high protein, low-allergy diets, and taking appropriate nutritional supplements, based on nutritional analyses before and during pregnancy in Foresight surveys.1 Also, none of my patients have reported postnatal depression when taking multiple tailored supplements over the last 25 years. However, zinc supplements taken alone can lower copper stores and result in reduced superoxide dismutase activities. This can cause severe depression which responds dramatically to alternating copper and zinc supplements. Animals eat their placentas, women do not, whether or not they have vaginal deliveries or caesarean sections. Therefore this excellent source of zinc, copper, iron and essential fatty acids is not utilized for lactation when the need for a high zinc intake and good serum zinc levels is greatest.8 However, toxic metals accumulate in placentas when zinc is deficient and high levels of cadmium, mercury, nickel, lead, aluminium relate to poor pregnancy outcomes.11 1 Grant ECG. Nutritional supplements to prevent pregnancy complications. http://bmj.com/cgi/eletters/329/7458/152#67502, 16 Jul 2004 2 Maes M, D'Haese PC, Scharpe S, D'Hondt P, Cosyns P, De Broe ME. Hypozincemia in depression. J Affect Disord. 1994 Jun;31(2):135-40. 3 Grant ECG. Re: Depression, Antidepressants, and Breast Cancer: Considering Only the "Facts" that Fit? http://bmj.com/cgi/eletters/329/7465/529#76040, 28 Sep 2004 4 Grant ECG. Schizophrenics need zinc and not DHEA or testosterone supplements. http://bmj.com/cgi/eletters/330/7484/158#95066, 1 Feb 2005 5 Grant ECG. Psychiatrists ignore science http://bmj.com/cgi/eletters/330/7485/260#94858, 30 Jan 2005 6 Jezerniczky J, Nagy Z, Dvoracsek E, Nagy B, Ilyes I, Csorba S. Trace elements in the serum of mothers and their children. Acta Paediatr Acad Sci Hung. 1976;17(3):193-7. 7 Roshni R Patel, Deirdre J Murphy, Tim J Peters, and for ALSPAC Operative delivery and postnatal depression: a cohort study.BMJ 2005; 0: bmj.38376.603426.D3v1 8 Kirksey A, Ernst JA, Roepke JL, Tsai TL. Influence of mineral intake and use of oral contraceptives before pregnancy on the mineral content of human colostrum and of more mature milk. Am J Clin Nutr. 1979 Jan;32(1):30-9. 9 Pathak P, Kapil U. Role of trace elements zinc, copper and magnesium during pregnancy and its outcome. Indian J Pediatr. 2004 Nov;71(11):1003-5. 10 Cengiz B, Soylemez F, Ozturk E, Cavdar AO. Serum zinc, selenium, copper, and lead levels in women with second-trimester induced abortion resulting from neural tube defects: a preliminary study. Biol Trace Elem Res. 2004 Mar;97(3):225-35. 11 Ward NI, Watson R, Bryce-Smith D, et al. Placental element levels in relation to fetal development for obstetrically "normal" births: a study of 37 elements. Evidence for effects of cadmium, lead, and zinc on fetal growth, and smoking as a source of cadmium. Int J Biosocial Res 1987; 9: 63-81. Competing interests: None declared |
|||
|
|
|||
|
James M. Howard, independent biologist Fayetteville, Arkansas, U.S.A.
Send response to journal:
|
Thank you for your response, Dr. Nehrlich. I am often visited with your "concern," or more accurately "derision." My principal hypothesis is that DHEA was selected by evolution because it "optimizes" replication and transcription of DNA. (In fact, I think this evolutionary "selection" gave rise to mammals. "Hormones in Mammalian Evolution," Rivista di Biologia / Biology Forum 2001; 94: 177-184) Therefore I think DHEA is involved in growth and differentiation of all tissues, some more than others. Therefore, I look for this connection in many diseases / disorders and normal growth and development and I find it. I have been doing this since 1984 and support for my hypothesis has been increasing yearly. Competing interests: None declared |
|||
|
|
|||
|
James M. Howard, independent biologist Fayetteville, Arkansas, U.S.A.
Send response to journal:
|
I will do this only once just as an example to answer your derision. Diabetes. 2005 Mar;54(3):765-9. Effect of dehydroepiandrosterone replacement on insulin sensitivity and lipids in hypoadrenal women. Dhatariya K, Bigelow ML, Nair KS. Endocrine Research Unit, Joseph 5-194, Mayo Clinic and Foundation DHEA (dehydroepiandrosterone) replacement is not part of the current standard of care in hypoadrenal subjects. Animal studies have shown that DHEA administration prevents diabetes. To determine the physiological effect of DHEA replacement on insulin sensitivity in adrenal-deficient women, we performed a single-center, randomized, double-blind, placebo- controlled, crossover study in 28 hypoadrenal women (mean age 50.2 +/- 2.87 years) who received a single 50-mg dose of DHEA daily or placebo. After 12 weeks, insulin sensitivity was assessed using a hyperinsulinemic- euglycemic clamp. DHEA replacement significantly increased DHEA-S (sulfated ester of DHEA), bioavailable testosterone, and androstenedione and reduced sex hormone-binding globulin levels. Fasting plasma insulin and glucagon were lower with DHEA (42 +/- 4.94 vs. 53 +/- 6.58 pmol/l [P = 0.005] and 178 +/- 11.32 vs. 195.04 +/- 15 pmol/l [P = 0.02], respectively). The average amount of glucose needed to maintain similar blood glucose levels while infusing the same insulin dosages was higher during DHEA administration (358 +/- 24.7 vs. 320 +/- 24.6 mg/min; P < 0.05), whereas endogenous glucose production was similar. DHEA also reduced total cholesterol (P < 0.005), triglycerides (P < 0.011), LDL cholesterol (P < 0.05), and HDL cholesterol (P < 0.005). In conclusion, replacement therapy with 50 mg of DHEA for 12 weeks significantly increased insulin sensitivity in hypoadrenal women, thereby suggesting that DHEA replacement could have a potential impact in preventing type 2 diabetes. Competing interests: None declared |
|||
|
|
|||
|
Ellen C G Grant, physician and medical gynaecologist Kingston-upon-Thames, KT2 7JU, UK
Send response to journal:
|
Dr Howard wants DHEA to be given for everything from postnatal depression to Alzheimer’s Disease, and now also for preventing diabetes. Why did 28 women aged about 52 have hypoadrenal function? Had they been using progestogen-dominant contraceptives or HRT. Megestrol acetate, which is very similar in action to the most commonly prescribed HRT progesterone in the USA, medroxyprogesterone acetate, causes hypoadrenalism.1 Adults previously treated (inappropriately with growth hormone instead of zinc) for idiopathic childhood onset growth hormone deficiency have a high risk of adrenal insufficiency as adults.2 A major cause of poor growth in childhood is zinc deficiency. This can be diagnosed using sweat or white blood cell concentrations, but not serum because serum levels tends to remain within the reference range, even in severe zinc deficiency in children. Fricker et al found that removal of the adrenal gland protected the thymus of zinc deficient mice from atrophy and also provided substantial protection of lymphopoietic processes.3 No type of androgenic hormone is essential for life. The only essentials are essential amino acids, minerals, vitamins and essential fatty acids. The incredibly widespread promotion of DHEA, thyroid, and sex hormones, for every condition and symptom reflects the universality of essential nutrient deficiencies, plus high levels of toxic minerals, in individuals living in “developed” societies and the continuing misuse of hormones. 1 Naing KK, Dewar JA, Leese GP.Megestrol acetate therapy and secondary adrenal suppression. Cancer 1999; 86 (6): J Am Coll Nutr. 1995 ;14(1):11-7.1044-9. 2 Lange M, Feldt-Rasmussen U, Svendsen OL, Kastrup KW, Juul A, Muller J.High risk of adrenal insufficiency in adults previously treated for idiopathic childhood onset growth hormone deficiency.J Clin Endocrinol Metab. 2003 ; 88(12): 5784-9. 3 Fraker PJ, Osati-Ashtiani F, Wagner MA, King LE. Possible roles for glucocorticoids and apoptosis in the suppression of lymphopoiesis during zinc deficiency: a review. J Am Coll Nutr. 1995; 14(1): 11-7. Competing interests: None declared |
|||
|
|
|||
|
Michel R Odent, Director. Primal Health Research Centre 72 Savernake Road.. London, NW3 2JR
Send response to journal:
|
The paper by Patel RR et al.1 should inspire further research at a time when we are learning about the anti-depressant effects of oxytocin.2,3,4 In the future we should contrast two modes of delivery. The focus should be on deliveries without any interference in the activity of the oxytocin system, compared with all the others. This reference group would include only women who gave birth to the baby and to the placenta without receiving any oxytocic agent. Let us recall that synthetic oxytocin administered by injection does not reach the brain receptors (does not cross the blood brain barrier) and does not have any behavioural effect. Furthermore it probably interferes with the release of the pituitary oxytocin via a feedback mechanism. Let us recall also that the highest peak of oxytocin a woman can possibly release in the perinatal period is during the third stage of labour.5 References: 1 - Roshni R Patel, Deirdre J Murphy, Tim J Peters, for ALSPAC. Operative delivery and postnatal depression: a cohort study. BMJ 2005;330:879-81. 2 - Arletti R, Bertolini A. Oxytocin acts as an antidepressant in two animal models of depression. Life Sci. 1987 Oct 5;41(14):1725-30. 3 – Frasch A. Reduction of plasma oxytocic levels in patients suffering from major depression. Advances in Experimental Medical Biology 1995: 257- 258. 4 - Uvnas-Moberg K, Bjokstrand E, Hillegaart V, Ahlenius S. Oxytocin as a possible mediator of SSRI-induced antidepressant effects. Psychopharmacology (Berl). 1999;142(1):95-101. 5 – Nissen E, Gunilla L, Widstrom AM, Uvnas-Moberg K. Elevation of oxytocin levels early post partum in women. Acta Obstet Gybnecol Scand 1995; 74: 530-33 Competing interests: None declared |
|||
|
|
|||
|
Sheena Fleming, Midwife Hampshire, United Kingdom
Send response to journal:
|
The conclusion by Patel et al (2005) that an emergency lower segment caesarean section (LSCS) and assisted vaginal deliveries are not associated with an increased risk of post natal depression (PND) left me and my midwfery colleagues feeling surprised. A feature of PND is a lowered self esteem and a loss of confidence and since both procedures are associated with feelings of powerlessness, lack of control and a reduced self-esteem for the woman following delivery (Soet et al, 2003), it would seem a reasonable conclusion that these unplanned intra-partum procedures will have an influence on the woman's mood. The sense of achievement following a spontaneous delivery is a powerful psychological boost to the start of a complex and complicated adjustment to motherhood. Women value normality-Simkin(1991)clearly describes how important the relationship is between a woman's sense of control, her expectations in childbirth and the association with emotional well-being and satisfaction with maternity care overall. Operative deliveries and emergency LSCS's are usually as a result of a 'failure to progress' and it my professional experience and that of my colleagues that women often express their disappointment at 'failing' to achieve a normal delivery. If this is not expressed at the time of the delivery, then a subsequent normal delivery will almost certainly highlight their dis-satisfaction at their previous experiences. The use of the Edinburgh Postnatal Depression Score (EPDS) may be widely used in the UK to detect PND, but how acceptable do women find it as a screening tool? Shakespeare et al (2003)have concluded that the majority of women in their study found it 'less than acceptable' and indeed some women reported that they were concerned about giving 'the right answer'. Birth is traditionally associated with joy, happiness and relief that both mother and infant have emerged healthy and consequently, some women may not feel it is 'appropriate' to feel dissatisfied with their birth experience. Richards(1990)suggests that the reported rate of women affected by PND may actually be as high as 22% ,since women may be reluctant to report it or seek treatment for it due to the stigma attached to depression generally. This paper has certainly prompted some discussion at work! but my experiences of delivering and caring for pregnant ladies has taught me that mode of delivery does has an effect on the post natal period. References: Richards JP (1990). Postnatal depression: a review of recent literature. British Journal of General Practice. 40 (340) p472-476. Simkin PT, (1991). Just another day in a woman's life? Women's lomg- term perceptions of their first birth experience: part one. Birth 18(4) p203-210 Cited: Moyzakitis W, (2004). Exploring women's descriptions of distress and /or trauma in childbirth froma feminist perspective. Evidence -Based Midwfery 2(1) p8-14. Shakepeare J, Blake F, Garcia J, (2003). A qualitative study of the acceptability of routine screening of postnatal women using the Edinburgh Postnatal Depression Scale. British journal of General Practice. 53 p614- 619. Soet JE, Brack GA, Dilorio CD, (2003). Prevelance and predictors of women's experiences of psychological trauma during childbirth. Birth 30(1) p36-46. Competing interests: None declared |
|||
|
|
|||
|
Roshni R Patel, Clinical Academic Training Fellow Division of Obstetrics & Gynaecology, University of Bristol, Deirdre J Murphy and Tim J Peters
Send response to journal:
|
We thank Fleming for her interest in our work although the conclusions she has drawn are at odds with the results of this methodologically robust study. We accept that it is a commonly held and plausible hypothesis that operative delivery in labour may be associated with postnatal depression (PND), and hence we undertook this study. The ICD 10 code produced by the World Health Organization uses a combination of special clinical features and onset within six weeks of childbirth for diagnosis of PND.1 We have reported ourselves that women may have feelings of low self-esteem, powerlessness and lack of control following operative delivery.2 These features may exist as a component of depression, but they should not be confused with the diagnosis of a serious mental illness. Fleming reports that her experience and that of her colleagues has shown that operative delivery will influence the woman’s mood. This may well be true, but does not fulfil the criteria for PND. Furthermore, the purpose of this study was to increase the evidence base for this topic rather than rely on clinical statements from personal experience that may lead to misrepresentation of the facts. Contrary to Fleming’s belief, failure to progress is not ‘usually’ the cause of emergency caesarean section, but one of several indications.3 Fleming also criticises the Edinburgh Postnatal Depression Scale (EPDS) and cites evidence that women found the screening tool as less than acceptable.4 The study interviewed 39 women of 172 that were invited and 54% found the test unacceptable. The representativeness of the small sample is unclear. The EPDS is currently the best screening tool available for the identification of postnatal depression. A review of 18 validation studies of the EPDS concluded that most studies show a high sensitivity.5 In a large community study it was found to have a sensitivity of 88% and a specificity of 93%.6 This paper provides some reassurance to women and clinicians. Despite the unplanned nature of operative delivery in labour and potential feelings of disappointment that may be associated with this, women were not at increased risk of postnatal depression. Clearly there is potential for other types of psychological morbidity following emergency operative delivery and we support the need for further research in this important area. References 1. World Health Organiziation. International Statistical Classifications of Diseases and Related Health Problems. ICD-10. Geneva: World Health Organisation, 1993. 2. Murphy DJ, Pope C, Frost J, Liebling RE. Women's views on the impact of operative delivery in the second stage of labour: qualitative interview study. British Medical Journal 2003;327(7424):1132. 3. Thomas J, Paranjothy S. The National Sentinel Caesarean Section Audit Report. RCOG Press: Royal College of Obstetricians & Gynaecologists Clinical Effectiveness Support Unit, 2001. 4. Shakepeare J, Blake F, Garcia J. A qualitative study of the acceptability of routine screening of postnatal women using the Edinburgh Postnatal Depression Scale. British journal of General Practice 2003;53:614-19. 5. Eberhard-Gran M, Eskild A, Tambs K, Opjordsmoen S, Samuelsen SO. Review of validation studies of the Edinburgh Postnatal Depression Scale. Acta Psychiatrica Scandinavica 2001;104(4):243-9. 6. Murray L, Carothers AD. The validation of the Edinburgh Post-natal Depression Scale on a community sample. British Journal of Psychiatry 1990;157:288-90. Competing interests: None declared |
|||
|
|
|||
|
Sheena Fleming, Midwife Hampshire, United Kingdom
Send response to journal:
|
I have read the comments made by Patel et al(1) with interest and thank them for the correction regarding the main indication of an Emergency Caesarean Section. While I do not doubt the methodology and subsequent analysis of data used in the study, my midwifery experience remains surprised at the the main conclusions of the cohort study. Of course not every woman who has undergone an unplanned surgical or operative delivery will develop PND-the authors are right to state that the development of this illness is much more complicated, but to conclude there is no link at all? I agree with Kotaska (2)when he questions the limits of evidence based medicine in investigating complex clinical and human phenomenona and I look forward to reading further studies in this particular area that are able to include qualitative data, in addition to any statistical analysis. References: 1. Patel R, Murphy DJ, Peters T (2004). Operative Delivery and Post -natal depression: a cohort study. British Journal of Medicine (330) p879 2. Kotaska A (2003). Inappropriate use of randomised controlled trials to evaluate complex phenonmena: a case study of vaginal breech delivery. British Journal of Medicine (329) p1039-1042 Competing interests: None declared |
|||
|
|
|||
|
Melissa A Collins, mom of two,1 c/s & 1 VBAC 94590
Send response to journal:
|
The authors of this study should sign up to and read the ICAN (International Cesarean Awareness Network) mailing list for a few days. You can get access at ican-online.org. ICAN is a grassroots organization focused on supporting women who have had, will have or wish to avoid a c-section. They also focus on supporting women who want to have a VBAC (vaginal birth after cesarean). If the authors had asked me or hundreds of other women who seek out ICAN every year how our surgeries affected us, this study would have had a very different outcome. I suffered PPD (Postpartum Depression) for eight months and cried almost daily about my surgery and everything that was lost from it. I am not alone. New mothers seek out ICAN on a daily basis to try to deal with the emotional toll that their operative delivery has had on them. I have read countless stories of sheer emotional agony over the events of an unexpected method of delivery that lasts for months and sometimes years. This study is very damaging, I think, because it continues the lie that cesarean is just another way to give birth and all that matters is a healthy baby. Too often in society we discount the mother and her needs, even though she must be both physically and emotionally healthy to give her family what it needs. Recently, the new statistics for 2004 were published by the CDC (Center for Disease Control). Now, 29.1% of pregnant women who walk into the hospital to have their babies walk out recovering from major abdominal surgery. Numerous studies done over the years show that over half of all c-sections performed in the US are either completely unnecessary or easily avoided by reducing other unnecessary interventions that are routine in hospitals today. I would like to see a good study done comparing PPD rates among women who birthed in a hospital compared to those who birthed at home. If method of delivery does not effect PPD rates, maybe it is the place of delivery or the attendants present. One thing is for sure, more research is needed, because a whole lot of mothers out their believe that the events surrounding birth do effect their emotional health and if that could be acknowledged maybe a lot of them could get the help they need. Competing interests: None declared |
|||